Insurance Appeal Letter — Free Template for a Denied Claim

Your denial letter, or explanation of benefits, should state the reason for the denial and how to appeal. Read it carefully. For health insurance, you can also request a copy of your claim file and the specific plan rule or clinical guideline the insurer used. That tells you exactly what your appeal has to overcome.

Then read the matching section of your policy or plan documents. If the policy supports coverage, quote the relevant language in your letter. If the denial was an error, such as a wrong code or a missing referral, ask your provider to correct and resubmit the claim, which may resolve it without an appeal.

For medical necessity denials, a letter from your doctor explaining why the treatment was necessary is usually the most important piece of evidence. Ask your doctor's office to include your history, treatments already tried and how the requested care meets the plan's criteria. Medical records and published guidelines support the letter.

Many provider offices handle appeals regularly and may submit one for you. Even so, sending your own letter as the patient can add useful detail about how the condition affects your life.

Deadlines vary by type of insurance and plan, so check the denial letter. For most health plans, you have an internal appeal with the insurer first, and if that's denied, you can usually request an external review by an independent reviewer. If treatment is urgent, ask for an expedited appeal. Your state's insurance department can explain your options and take complaints.

Many decisions have more than one level of review. A denied first appeal can often be taken to a higher authority, such as a dean or provost, a higher level of the agency, an independent reviewer or a formal hearing. Your decision letter or the organization's policies usually explain the next step and its deadline.

If you don't get a response, follow up in writing, refer to the date you sent your appeal and ask when you can expect a decision. Keep a log of every contact. For insurance, government benefits or employment matters, a state agency or ombudsman may also be able to help.

For high-stakes decisions, such as losing a job, benefits, insurance coverage or your place at a school, consider getting help from a legal aid organization, a union representative, a student advocate or a patient advocate. Many offer free or low-cost assistance.